Provider Demographics
NPI:1083287395
Name:PUNTA GORDA HMA PHYSICIAN MANAGEMENT LLC
Entity Type:Organization
Organization Name:PUNTA GORDA HMA PHYSICIAN MANAGEMENT LLC
Other - Org Name:NEUROLOGY CENTER OF SOUTHWEST FLORIDA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIR PROV ENROLLMENT & ONBOARDING
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-465-7211
Mailing Address - Fax:615-628-6877
Practice Address - Street 1:713 E MARION AVE STE 129
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3868
Practice Address - Country:US
Practice Address - Phone:941-833-1580
Practice Address - Fax:941-621-8977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-23
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278522610Medicaid